MEDICARE: NICHOLAS RYAN BIBEAU DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	LPT-30635	AZ

General Provider Information

NPI Number	:	1174022990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS RYAN BIBEAU DPT

Provider Business Mailing Address
First Line	:	625 KENMOOR AVE SE STE 100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2395
Country	:	US
Telephone Number	:	616-356-5000
Fax Number	:	616-356-5001

Provider Business Practice Location Address
First Line	:	1075 S IDAHO RD STE 210
Second Line	:
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85119-6405
Country	:	US
Telephone Number	:	480-983-0877
Fax Number	:	480-983-3172

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2018
Last Update Date	:	12/09/2025

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